Pelvic Pain Questionnaires - Oklahoma Physical Therapy






Pain Disability Index

Center for Urologic and Pelvic Pain

In order to determine how effective your treatment is, we need to know how much pain is interfering in your normal activities. For the 7 areas listed below, please circle the number on the scale which describes the level of disability you have experienced in each area OVER THE PAST WEEK. A score of "0" means no disability at all, and a score of -10- indicates that all of the activities which you would normally do have been totally disrupted or prevented by your pain over the past week. Circle "0" if a category does not apply to you.

Family/Home Responsibilities: This category refers to activities related to the home or family. It includes chores or duties performed around the house (e.g. yard work,
house cleaning) and errands or favors for other family members (e.g. driving the children to school.)
No Disability
Mild
Moderate
Severe
Total Disability

Recreation: This category includes hobbies, sports, and other similar leisure time activities.
No Disability
Mild
Moderate
Severe
Total Disability

Social Activity: This category refers to activities which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions.
No Disability
Mild
Moderate
Severe
Total Disability

Occupation: This category refers to activities that are a part of or directly related to one's job. This includes non-paying jobs as well, such as housewife or volunteer worker.
No Disability
Mild
Moderate
Severe
Total Disability

Sexual Behavior: This category refers to the frequency and quality of one's sex life.
No Disability
Mild
Moderate
Severe
Total Disability

Self-Care: This category includes activities which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed).
No Disability
Mild
Moderate
Severe
Total Disability

Life-Support Activity: This category refers to basic life-supporting behaviors such as eating and sleeping.
No Disability
Mild
Moderate
Severe
Total Disability

VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (VQ)

1. Because of my pelvic pain

2. My pelvic pain

3. My pelvic pain

4. Because of pain pills I take for my pelvic pain

5. Because of my pelvic pain

6. Because of my pelvic pain

7. Because of my pelvic pain

8. Because of my pelvic pain

9. Because of my pelvic pain

10. Because of my pelvic pain

11. Because of my pelvic pain

For scorers (patient should not see these directions): To score the VQ, add numerical values assigned to each response. These appear next to the check-boxes. The higher the score the greater the functional limitation. A diminishing score represents improvement.

Hummel-Berry K, Wallace K, Herman H. Reliability and validity of the Vulvar Functional Status Questionnaire. JWHPT. 2007; 31:3.

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